WHO HIS SDS 2018.13 Eng PDF

Partnership
preparation
package
A practical guide to
implementing twinning
partnerships
WHO Twinning
Partnerships
for Improvement
Partnership
preparation
package
A practical guide to
implementing twinning
partnerships
WHO Twinning
Partnerships
for Improvement
2 Partnership Preparation Package
WHO/HIS/SDS/2018.13
© World Health Organization 2018
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Printed in Switzerland
CONTENTS
6 ABBREVIATIONS
8 INTRODUCTION
12 PART 1: TPI OBJECTIVES
26 PART 2: OVERVIEW OF THE 6-STEP CYCLE
PART 3: DIGGING DEEP - PUTTING THE

28
6-STEP CYCLE INTO PRACTICE
42 KEEPING THE LEARNING GOING
44 REFERENCES
46 ANNEXES
62 BIBLIOGRAPHY
ACKNOWLEDGEMENTS
The World Health Organization (WHO) would like to acknowledge the support and contribution
that many individuals and organizations have made to the development of this document.
Katthyana Aparicio, Melissa Kleine-Bingham and Shams Syed (Department of Service Delivery
and Safety, WHO) coordinated and led the development and writing of this document. Maki
Kajiwara, Nana Mensah Abrampah, Julie Storr (Department of Service Delivery and Safety,
WHO) provided significant input to the development and drafting of this document.
Special thanks to Sandra Hwang and Albert Wu (Johns Hopkins Bloomberg School of Public
Health) for their technical contribution on quality improvement methods.
External Peer Review Group

Ngormbu Jusu Ballah (Liberia Ministry of Health), Jean Marc Chapplain (Centre Hospitalier
Universitaire de Rennes), Graeme Chisholm (Tropical Health Education Trust - THET), Eric
de Roodenbeke (International Hospital Federation - IHF), Charlie Evans (American College
of Healthcare Executives), Koichi Izumikawa (Nagasaki University Hospital - NHU), Farid
Lamara (Expertise France), Emmanuelle Maurin (Expertise France), Sandra Hwang (Johns
Hopkins Armstrong Institute for Patient Safety and Quality), Andrew Jones, Samuel Seeigbeh
(Tellewayon Memorial Hospital, Liberia) Albert Wu (Johns Hopkins Bloomberg School of
Public Health) and ESTHER Alliance for Global Health Partnerships.
ABBREVIATIONS
AHRQ Agency for Healthcare Research and Quality
AMR antimicrobial resistance
APIC Association for Professionals in Infection Control
APPS African Partnerships for Patient Safety
EEA ESTHER Alliance for Global Health Partnerships
GLL Global Learning Laboratory
HSAs Health Surveillance Assistants
IHF International Hospital Federation
IPC infection prevention and control
LMICs low- and middle-income countries
M&E monitoring and evaluation
NHS National Health System
NUH Nagasaki University Hospital
OECD Organisation for Economic Co-operation and Development
PDSA Plan-Do-Study-Act
QI quality improvement
SARA Service Availability and Readiness Assessment
SDGs Sustainable Development Goals
SMS short message services
SWOC Strengths, weaknesses, opportunities and challenges
THET Tropical Health Education Trust
TMH Tellewayon Memorial Hospital
TPI Twinning Partnerships for Improvement
UHC universal health coverage
USAID United States Agency for International Development
WASH water, sanitation and hygiene
WISN workload indicators of staffing needs
WHO World Health Organization

INTRODUCTION
BACKGROUND
T
winning partnerships between health
institutions are an innovative approach that
can be used to improve various aspects
of health service delivery. The WHO Twinning
Partnerships for Improvement (TPI) model supports
long-term efforts on quality health service delivery
within the context of achieving universal health
coverage (UHC). The work can contribute to building
resilient health systems. Fundamental in the approach
is to prioritize alignment with national health
plans and strategies, while working to achieve the
Sustainable Development Goals (SDGs).
TPI builds on the learning from the WHO African
Partnerships for Patient Safety (APPS) programme (1).
These rich lessons and the subsequent application of
twinning partnerships in the recovery effort in Ebola-
affected countries have facilitated the design of WHO
TPI. The key aim of WHO TPI is to support health care
facilities in the improvement and enhancement of the
quality of their service delivery, while aligning with the
overall national strategic direction on improving
quality service delivery.
WHO TPI Snapshot
• Twinning Partnerships for
Institutional health partnerships can play a critical
Improvement focuses on
role in health systems strengthening. This has been
the value of institution-to-
increasingly recognized across the world. Many
institution partnerships in
global health groups1 have highlighted the need to
catalyzing health service
“promote the utility of institutional health partnerships
improvement.
in strengthening health systems and in delivering
effective health services.” Recognizing the synergy • The hospital-to-hospital
that comes from a partnership approach, national model developed by ‘African
policy documents over the past decade have also Partnerships for Patient Safety’
begun to highlight the potential for institutional (APPS) is the foundation on
partnerships as an entry point to strengthen services which TPI has been developed.
and health systems. The emphasis is on a ‘doing
while learning” model (3).
In addition to the APPS programme, TPI also builds on • As a global network of twinning
the work undertaken in applying the Twinning model partners develops there is an
to support recovery from the 2014 West Africa Ebola opportunity to learn from and
outbreak. TPI Recovery focused upon building resilient share learning across the TPI
health systems and reactivating safe essential health network.
services in those countries most affected by the
outbreak. The aim of TPI Recovery was to rebuild the • The approach promotes
health services in order to support implementation of collaboration, co-development
national recovery plans (2). and sharing of both tacit
and explicit knowledge
Implementation of twinning partnerships involves thus enhancing spread of
addressing a variety of service delivery and clinical successful approaches to
care areas, including, but not limited to, infection improvement.
prevention and control (IPC); patient safety; and
specific clinical services. Health workforce capacity-
building is embedded within the model. TPI can feed
into work at the national level to improve the quality
1
For more information on global health groups and to view the
consensus statement, please visit WHO’s web site at: http://
www.who.int/patientsafety/implementation/apps/global-catalyst-group.
pdf?ua=1
of service delivery. These partnerships can act as a

valuable tool for health improvement strategies and
bring real benefit to the front line of service delivery
and ultimately to the health of an entire population.
The power of twinning partnerships working together
can bring effective health improvements beyond what
an individual organization or team could achieve
alone (4). Furthermore, the work of such twinning
partnerships can feed into national strategic efforts to
improve quality service delivery elsewhere.
PURPOSE OF THE TPI PREPARATION

TPI brings an
PACKAGE opportunity to support
The aim of this document is to provide a practical improvement in the
step-by-step approach for any health institution delivery of care at the
interested in improving the quality of health service local, sub-national and
delivery through twinning partnerships. national levels. It can
act as a catalyst for
The model is based on a 6-step cycle which change in efforts to
begins when two or more partners agree on the enhance quality in the
establishment of the partnership. TPI guides the context of UHC.
partners through a systematic process which
involves identifying some specific areas for
improvement, developing an action plan to implement
improvements, and then evaluating the progression
and changes made towards improvement.
Institutional health partnerships have the potential

not only to work as individual partnerships, but also
to collaborate with other partnerships to support a
national network of similar partnerships. This can
support national efforts through joint problem-solving Who benefits
and sharing experiences in order to develop a body
of evidence and experience that can inform national from TPI?
and district authorities. This can further encourage
application of the partnership model at all levels of the • Health workers
health system. • Hospitals
• Health facilities
TARGET AUDIENCE
• Patients
The target audience for this partnership preparation
• Communities
package are those committed to improving the quality
of healthcare and service delivery including, but not • Quality strategists
limited, to those in: • National policy-makers
introduction 11
• health institutions
• health facilities
• academic/research institutions
• professional associations When to use the
package
• donor organizations
• health authorities The package will be
useful to any new
• policy making
or existing twinning
• governments. health institutions in
order to work through
The TPI preparation package also aims to inform a partnership-based
decision-makers and authorities working at the approach to improve
national level that are responsible for planning, the quality of health
developing, implementing and evaluating national services and embed
health strategies, including WHO country offices and the effort within
ministries of health. long-term service
improvement.
What is APPS?
The WHO African Partnership for Patient Safety (APPS) was a results-oriented hospital-to-
hospital approach to improvement. The emphasis of APPS was on the joint development of
solutions based on mutually beneficial partnerships. Infection prevention and control, safe
surgery, waste management and health worker safety were central elements of the APPS
partnership work providing a common goal. APPS resulted in a range of implementation
experience across the participating countries and reinforced the value of partnerships
in motivating staff, increasing commitment to change, strengthening capacity-building
and ultimately impacting on the quality and safety of patient care. The APPS approach
is an example of how partnerships have the potential to strengthen the delivery of health
services for the benefit of the wider community, as well as the participating health facilities
themselves (1).
PART 1:
TPI OBJECTIVES
OVERVIEW OF OBJECTIVES
T
PI focuses on the value of institution-to-
institution partnerships in catalysing health
service improvement following a “doing while
learning”2 model. TPI takes into account a variety
of entities, including health facilities, academic
institutions, private institutions, etc.3 It provides the
potential for implementing different types of
2
”Doing while learning” refers to the experiential learning theory
where one learns from experience in order to develop skills or new
ways of thinking. (Lewis and Williams 1994, p.6)
3
While a variety of entities can be involved in the partnerships, the
TPI preparation package will use the generic term institutions to
cover all types of entities.
Twinning Partnerships for Improvement - Objectives
partnerships, at local, sub-national and national level,

and also across continents. Institutions from high-
income countries or from low- and middle-income
countries (LMICs) can initiate partnerships to support
other institutions within LMICs and thus provide
unique opportunities to catalyse the move towards
quality health services, all within the context of The ultimate
achieving universal health coverage. benefits of TPI are
bi-directional learning
Within the TPI model, there are three objectives that and improvement,
each partnership should focus on achieving. motivated and
committed staff;
1. The first objective is the development of the strengthened delivery
partnership. This objective focuses on fostering a of health services;
strong bi-directional partnership between health and better patient
institutions. and health worker
2. The second objective is improvement through outcomes.
implementing effective interventions based
on needs identified at the front lines of service
delivery. The Recovery Toolkit
3. The third objective is to spread the learning and
experience within the local and national health
system and also beyond.
The TPI approach provides a measurable

What is
improvement process that uses a validated set of
co-development?
tools. By participating in TPI, partners gain knowledge,
cultural awareness and share learning on innovative A process that
approaches towards improvement. As a global brings together the
network of twinning partners emerges, there is an collective intelligence
opportunity to learn from and share learning across for a collaborative
the larger TPI network, to promote collaboration, development and
co-development and sharing, and support the spread applies joint decision-
and replication of improvement. making that enhances
trust.
PART 1: TPI objectives 15
OBJECTIVE 1 – PARTNERSHIP
The formation of a partnership is the first step in the
TPI journey. Under the first objective, two or more
institutions come together to agree upon a common
goal and define the partnership priorities which they
hope will result in sustainable improvements at
the health facility. Building on the APPS definition
of partnership, which encompasses a sociological
perspective focusing on the interaction of people,
TPI has identified several values essential in building
successful partnerships (1). These are:
1. collaborative relationships
2. trust
3. equality
4. mutuality
5. shared accountability
Definition of
6. transparency. partnership
“A partnership
Building on the TPI values and the APPS partnership
can be defined as
definition, the TPI principles below can be applied
a collaborative
when implementing a partnership4. These principles
relationship between
can provide a foundation for forming and maintaining
two or more parties
an effective and sustainable partnership.
based on trust,
Shared vision and joint planning equality and mutual
• Coordination and mutual agreement in setting understanding, for
objectives, time frames and an approach to the achievement
evaluation. of a jointly agreed
goal. Partnerships
• Co-developing and establishing partnership plan
involve risks as well as
and activities.
benefits, making shared
• Mutually agreeing on key performance measures accountability critical.”
to assess impact.
~APPS, 2009-2011
4
These are a set of principles that have emerged from previous part-
nerships but should be adapted to the context of each partnership.
It is important and useful to recognize similar partnership princi-
ples that have been established by a range of organizations (e.g.
THET; ESTHER Alliance for Global Health Partnerships).
Ownership
• Ensuring that ownership is supported by each arm
of the institution and not individuals.
• Involving and engaging stakeholders by developing
an effective stakeholder strategy that emphasizes
roles, responsibilities and commitments.
• Strategizing and planning for the involvement of
all levels of the health system.
Good relationships
• Building relationships based on trust, non-
judgement and commitment.
• Harnessing the passion and power of individuals.
• Respecting and understanding local rules, culture
and customs.
Good communication
• Communicating effectively to facilitate decision-
making and information-sharing.
• Agree on and securing channels for decision-
making.
• Clearly identifying focal points5 and the roles of
each team member.
Ways of working
• Nurturing individuals to be self-motivated and
considering the value of having a good sense of
humour.
• Building transparency, flexibility and adaptability
into the partnership (while keeping an eye on the
changing external environment).
• Celebrating what went well and modifying what
has not gone well.
5
Focal point can be defined as the designated or referent person
serving as a coordinator of information related to a project, a pro-
gramme or a specific activity.
The power of partnerships

There is a growing understanding that health
partnerships work in synergy to yield powerful results
– the combined efforts often having greater impact
“We were able to move
than work in isolation.
faster towards our goal
than we would have on
Both arms of the partnership benefit6 from learning
our own” (5).
about innovative practices coming from unique and
unexpected sources. Sometimes this leads to lower ~Dr Emanuel Addo-
costs for the same or better outcomes. For example, Yobo, Komfe
the partnership between Church of Uganda Kisiizi Anokye Teaching
Hospital and Countess of Chester Hospital NHS Hospital, Ghana
Foundation Trust maximized the local resources and APPS Partnership
was able to obtain alcohol from local agriculture to Strength Survey, 2012.
produce hand-sanitizer. This innovative approach
exposed and sensitized both arms of the partnership
to “out of the box” thinking in order to make
improvements.
SDG 17
Revitalize the global partnership for sustainable development (6).
Targets relating to TPI
• SDG Target 17.6: “Enhance North-South, South-South and triangular regional and
international cooperation on and access to science, technology and innovation and
enhance knowledge sharing on mutually agreed terms, including through improved
coordination among existing mechanisms, in particular at the United Nations level, and
through a global technology facilitation mechanism.”
• SDG Target 17.9: “Enhance international support for implementing effective and targeted
capacity-building in developing countries to support national plans to implement all the
sustainable development goals, including through North-South,
South-South and triangular cooperation.”
6
More information about benefits for each partner can be found
here: https://www.ache.org/pdf/nonsecure/White-Paper-International-Hos-
pital-Partnerships.pdf
Partnerships and the global goals

The twinning partnership approach provides a link
between local institutional change, national health
systems and the global arena. The SDGs acknowledge
the importance of partnerships (Objective 17) by
recognizing that partnerships help to “mobilize and
share knowledge, expertise, technology and financial
resources.” The SDG goes further to highlight that “a
successful sustainable development agenda requires
partnerships between governments, the private
sector and civil society. These inclusive partnerships
built upon principles and values, a shared vision,
and shared goals that place people at the centre,
are needed at the global, regional, national and local
level” (6). Linkages with multiple SDGs are evident,
particularly 3.8 on UHC, but a range of others are
clearly evident too. For example, a partnership
approach can contribute to the reduction of maternal
mortality ratio (SDG 3.1) by improving the quality of
care for mothers.7
While TPI focuses on local, front-line improvements

in the quality of health services, the compounding
results from all partnerships around the world can
lead towards global cohesion and overall impact. It
is important to note that the benefits produced by
twinning partnerships not only enhance institutional
capacity to deliver improved health services, but
also contribute to strengthening of the entire health
system, if designed and implemented effectively.
OBJECTIVE 2 – IMPROVEMENT
Improvement is at the core of the partnership. In
general, improvement focuses on the act or process
of making something better. In hospital settings,
improvement implies organizational and structural
change, in addition to a necessary change in attitudes
and behaviour, very often - all of which makes this
process complex since it involves people and often
requires a culture shift. Gaps existing in quality of
care within health care facilities should be agreed
7
Royal College of Midwives and Ugandan Midwives Association.
Case study in THET: https://www.thet.org/case-studies/aligning-partner-
ship-plans-institutions-strategic-plan-2/
Partnership development and continued

strengthening – Japan and Liberia
The Partnership between Nagasaki University Hospital (NUH), Japan, and
Tellewayon Memorial Hospital (TMH) in Lofa County, Liberia, was formed in
August 2016. At the time, TMH was recovering from the West African Ebola
outbreak of 2014 and relying on international support to reactivate its essential
health services and moving forward with recovery efforts in alignment with
national recovery plans.
During the recovery at TMH, it was quickly realized that the impacts of the Ebola
response had depleted many resources and that extensive work was needed
in order to improve quality. NUH saw that the needs at TMH were extensive
and agreed to form a partnership with TMH. The Ministry of Health and the
County authorities in Liberia supported this partnership at the onset of the
formal TPI agreement. Careful consideration was given to the architecture of
the partnership, recognizing the distinct culture and context of the respective
partners. Principles and definition of partnerships were carefully considered in
recognition that success of the partnership would depend on the foundations
developed in the early stages. This proved pivotal in the roll-out of the
partnership.
Moving forward from this initial partnership, a situational assessment and gap
analysis were completed at TMH in October 2016. Following the gap analysis,
an official “action planning” meeting took place in December 2016 where both
partners agreed to improve infection prevention and control, with specific
attention being given to hand hygiene and waste management. It was noted that
by improving these two areas, the foundation could be created for overall quality
improvement throughout the whole hospital.
The partnership undertook two partnership exchange visits in Liberia and Japan
respectively. The principles of the partnership were reinforced throughout
while the improvement work proceeded. The bi-directionality of the partnership
learning was emphasized. For example, the TMH team leader gave a talk about
their experience in the Ebola response. NUH stated they benefited greatly from
because they learned about the realities of diagnosis and treating Ebola affected
patients.
upon. Based on these identified gaps, one or several

priority action areas are identified to steer the focus
of the partnership. The ultimate aim is to improve the
quality of care and overall health outcomes through
the successful implementation of interventions using
effective improvement methods. Both arms of the
partnership need to establish common goals and
priorities in order to develop a strong, effective and
sustainable partnership. Additionally, when defining
areas of improvement, it is necessary for the focus Improvement
to involve and engage local stakeholders, teams
and individuals within the health system who will “The combined and
be the ones to sustain the efforts put forth by the unceasing efforts of
partnership. everyone—healthcare
professionals,
Objective 2 involves the following necessities. patients and their
families, researchers,
• Both arms of the partnership needing to jointly payers, planners and
agree on improvement entry points. This collective educators—to make the
approach promotes an atmosphere of ownership, changes that will lead to
learning and innovation through a safe space better patient outcomes
supporting an open mind-set, the use of skills and (health), better system
an opportunity to work and learn together. performance (care)
and better professional
• Achieving common goals set between partners.
development (learning).”
This includes defining clear targets, agreeing on
the best methods of spread, setting clear reporting Batalden, P. B., &
mechanisms and monitoring standards, methods Davidoff, F. (2007). What
and ways of working. is “quality improvement”
and how can it transform
• Coordinating the implementation of improvement
healthcare? Quality &
activities through regular contact supported
Safety in Health Care,
by a communication plan that holds people
16(1), 2–3.
accountable for their own work.
https://qualitysafety.bmj.
• Testing several changes until a desired process
com/content/16/1/2
that leads to a desired outcome is achieved,
allowing for a certain degree of flexibility,
permitting necessary changes and adaptations.
The TPI approach provides a measurable

improvement process that uses a validated set of
tools. By participating in TPI, partners gain knowledge,
cultural awareness and share learning on innovative
approaches to improvement. Areas of improvement
can include a variety of service delivery and clinical
care areas influenced by the baseline assessment,
such as infection prevention and control (IPC), patient

safety, and specific clinical services.
Examples abound but the unifying concept is that Improvement –

improvement in service delivery needs to have
a direct and lasting impact on the quality of the
Gondar, Ethiopia and
entire health system8. The linkages between service Leicester, England
delivery and health workforce are clearly evident.
The inter-relatedness with each of the health system The partnership formed between
components is highlighted through all partnership the University of Gondar Hospital,
action. In the example below, the partnership in in Ethiopia and the University
Ethiopia illustrated how improvements in both service Hospital of Leicester NHS Trust, in
delivery and clinical care at the facility level have had England, aimed to implement the
a direct impact on the wider health system. Ultimately, WHO Surgical Safety Checklist in
achieving quality at the facility level can bring balance the operating theatres of Gondar
and improvements to the entire health system. Hospital. Through regular audits,
staff feedback and multidisciplinary
OBJECTIVE 3 – SPREAD learning sessions, the monitored
Spread allows for sharing and scale-up of results showed that the Checklist
improvement experiences and learning within the had successful implementation,
local and national health system, and beyond (7). This compliance and adherence among
enhances the reach and impact of the partnership staff. Additionally, there was
by sharing what did and did not work well. When consistent focus on joint learning and
considering Spread, a strategy to help document participation which helped to build
successful experiences should be developed and early research capacity. This resulted in
conversations should be held on the following topics: a multi-country research project to
look at Checklist implementation in a
(1) What are the new and creative health service partnership context. After monitoring
improvements that have been made? Spreading the the implementation of the Checklist
emerging success stories of improvement can help programme, it was found that its use
drive large scale spread. rose from 17% to 53%, with a 100%
application in emergency procedures.
(2) What are the ways in which this improvement will Multi-professional groups are now
be sustained? A way to sustain improvement is to trained in its use. Importantly, the
allow sufficient time for new practice to become fully research also provided an opportunity
integrated as the standard (e.g. incorporating new to critique the work of the partnership
practices in policies, procedures, job description, etc.). and enable further improvements. Of
note, this long-standing partnership
(3) How was the improvement made? For example, benefitted from the support of both
demonstrating the benefits and advantages arising THET and WHO (8).
8
A health system has traditionally been described by WHO as
comprised of six building blocks which include: leadership and
governance; health information systems; health financing;
essential medical products and technologies; human resources
for health; and service delivery.
from a new practice encourages both spread and

sustainability.
(4) Who is the target audience of the Spread? In

considering the target audience, it is important to
acknowledge if the spread will focus on individual
buy-in, whole facility buy-in, or entire health system
adoption. These details help to organize and structure
a plan to disseminate the information and experiences
of success.
The work of the partnership, particularly in relation to

spread, needs to take careful account of the national
strategic direction on quality, where this exists. Many
countries are now developing or refining national
quality policies and strategies. The formation of
these policies and strategies can be informed by
experiences that emerge from twinning partnerships.
When these national strategies already exist, the
work of the twinning partnerships should be carefully
aligned with the national direction. This allows the
effort of the partnership to have maximal impact by
supporting implementation of a nationally owned
drive for quality. The initial situational assessment can
identify the national quality direction and both arms
of the partnership need to be fully aware of this at all
stages of the partnership.
Spread can be considered in three ways - horizontal,

vertical and spontaneous (7)(9). From the onset of the
partnership, the following should be considered.
1. As soon as partners begin planning for health

facility improvement, spreading this improvement
should also be discussed.
2. Consider broadcasting your improvement message
through different channels, such as conferences,
professional journals, media, word-of-mouth and
first-hand accounts.
3. Make it as appealing as possible for others to
want to copy your improvement.
4. Build a network to sustain and grow spread.
5. Finally, consider, at the outset, how the experience

arising from this project could be used to feed into
learning systems, both at the national and global
levels.
Horizontal spread refers to spreading improvement

across people and organizations within the same level
of a health care system. An example of horizontal
spread is replicating improvements from one unit in a
health facility to another.
Vertical spread refers to spreading the information

and improvement efforts throughout the national,
subnational and local levels of a health system.
Vertical spread is particularly important because while
national level can drive local change, local can also
drive national level change. It is important to collect
quantitative data and analysis of the improvements
as it lays the groundwork for evidence-based practice
and can be a critical component of vertical spread,
and thereby influence changes in policy.
Spread requires strong connections between quality

improvement evidence in conjunction with both
facility and national quality policies. This evidence
and clear alignment with existing policy could help to
facilitate the improvements made from TPI into facility
and national quality policies.
Spontaneous spread, is not planned for, but can

spontaneously occur through informal channels
such as social networks, or opinion leaders, which
sometimes cross country’s borders. An example
of spontaneous spread is the engagement that
occurs between partnership facility leaders and key
influencers within the health system. The power of
human interaction and storytelling – often in informal
meetings and gatherings – in achieving change then
becomes clearly evident.
Of further note is the necessity to consider the spread

of ideas, competencies and skills from low-income
countries to partners in high-income countries. This
is inherently related to concepts of mutuality that are
enhanced through partnerships.
Spread - Yagaldo
Ouedraogo
The critical role of the community Hospital,
Involving patients and communities can stimulate
spread and strengthen implementation and the
Burkina Faso
sustainability of improvement programmes. and Montpellier
Connecting with the local community can improve
the quality of care and make services more people- Hospital, France
centred. This is particularly important in low-resource
settings where demand for health care is high. Co- Yagaldo Ouedraogo Teaching
developing health services around the needs of Hospital in Burkina Faso started
patients and the community, by empowering patients partnering with the Teaching
and communities by informing them and giving them Hospital of Monpellier in
the ability to make decisions in order to instigate France, and implemented a
change, can enhance the patient’s experience, pilot project to improve hygiene
health outcomes, confidence and trust in health care in the neurosurgery ward in
providers (10). Ideally, patient, family and community 2013. The objective was to
engagement should be part of all national health meet the standards of hospital
plans. In the absence of a formal mechanism to hygiene in this specific ward.
engage patients and the community, health care Four areas were targeted: hand
workers can carry out simple actions to engage them, hygiene, waste management,
such as providing practical training (e.g. on hand management of nosocomial
hygiene, waste management, use of medicines, etc.), infections and capacity-building
invite patients’ representatives or community leaders of health workers. The idea
to participate in orientation meetings and provide on- was to concentrate efforts on
going support. the selected activities in one
of the wards of the hospital
Advocating for the partnership and the successes in order to understand what
achieved will promote the work and lead to further kind of improvements could
interest within communities. This work can be then be replicated in other
celebrated and advertised to maintain motivation wards and units of the hospital.
and create a positive atmosphere. When community Improvement was spread
spread occurs, the knowledge generated through horizontally, making the entire
an improvement process in the health care facility facility benefit. Furthermore,
becomes part of normal practice and standards that convinced of the advantages
have positive implications for the population’s health, of partnerships work, Expertise
e.g. hand hygiene improvement. France secured support from the
European Commission to spread
The example below highlights horizontal and vertical this improvement to other health
spread. care facilities across the country.
Nine partnerships involving
national and regional hospitals
have been implemented since
February 2017 with positive
implications for the entire health
system of Burkina Faso. Thus,
horizontal and vertical spread is
taking place simultaneously (11).
PART 2: OVERVIEW OF
THE 6-STEP CYCLE
T
he partnership approach is a step-wise
approach which facilitates the development
of partnerships, the systematic identification
of gaps and the development of an action plan and
evaluation cycle.
1. Partnership development begins the

formal establishment of a fully functioning,
communicative twinning relation between two
or more health institutions. Both arms of the
partnership agree to work together to improve the
quality of health care.
2. The needs assessment allows for the baseline
needs of the health facility to be identified
and understood. This forms the basis for the
gap analysis and ultimately, guides all future
improvement activities of the partnership.
3. The gap analysis involves a review of the needs
assessments and reveals key priority areas for
action. From the gap analysis, the foundation for
action planning is established in a systematic
way, in order to help partners to implement a more
focused improvement effort.
4. Action planning brings partners to a jointly agreed
written plan of action. This action plan is grounded
in the gap analysis and sets clear short-term and
long-term targets for the twinning partnership. In
this step, it is important to look at communication,
spread and budget.
5. Action is the start of implementing the agreed
improvement activities set forth by the action
plan. By this stage, partners have established and
strategized about methods of action and have
secured communication channels for ongoing
partnership action.
6. Evaluation and review enables twinning
partnerships to assess the impact of both their
technical improvement work and the strength
and functioning of their twinning relations.
This reflects on the strengths and gaps of the
partnerships so that refinements can be made.
A variety of tools and resources are available

(Annex 2) to support each step and will guide the
partnership implementers throughout the process.
PART 3:
DIGGING DEEP -
PUTTING THE
6-STEP CYCLE INTO
PRACTICE
A
t each step of the cycle, one or more tangible
outputs or deliverables to work towards is
expected. These outputs are designed to help
the TPI partnership move the action forward. To assist
partners, a list of supportive tools and resources is
provided in annex 2.
Implementing organizational and structural change

is often complex, because in many cases it involves
people and a cultural shift needs to take place.
For this reason, when seeking appropriate tools
for any given technical action area, it is important
to consider how they can support planning for the
partnership activities, their implementation, and in
addition important cross-cutting themes, such as
community engagement, knowledge management and
communication/advocacy.
It is also important to consider the broader national
context, policies, frameworks and national strategic
priorities and existing initiatives in planning twinning
activities. Technical improvements must align
with national policies and strategies. This will be
particularly important in achieving objective 3
Core resources
and spreading the experience from the twinning
for Step 1 – Partnership
partnership improvement process both in the short
(see annex 2)
and long term.
STEP 1: PARTNERSHIP DEVELOPMENT

This is the beginning of the formal establishment of
a fully functioning, communicative twinning relation
between two or more health institutions (1)(4). Both
arms of the partnership agree to work together
to improve the quality of health care, focusing on Outputs or
different aspects of service delivery, including clinical
care. deliverables
A requirement of successful partnership 1. Exchange of letters between
implementation is to have a stable funding structure. institutional management
This has to be defined from the beginning, as the as required (it can be a
activities that the partners will undertake will depend letter of commitment
on the availability of human and financial resources or a Memorandum of
(4). Partnerships established through international Understanding).
cooperation9 can benefit from direct funding of one 2. Agreement on a definition of
arm of the partnership. In other cases, partners can the twinning partnership.
agree to share the costs or compete successfully for
external funds. This requires the partners working 3. Team members on each arm of
together to identify potential sources of funding and the partnership selected and
develop joint proposals. Whatever model of funding is contact details exchanged.
applied to implement the activities of the partnership, 4. Communication plan drawn up.
it is vital that partners agree on clear systems and
5. Kick-off meeting notes
procedures.
indicating potential areas
of work, next steps and a
Main activities
tentative date for conducting
1. Secure formal management and leadership the needs assessment.
agreement on both sides of the twinning
6. Official designation of a lead
partnership to take joint action. This can be done
and deputy trained in the
through a written statement of understanding
approach using the outline
across the institutions, such as a letter of
provided in this preparation
commitment.
package.
9
The concept of international cooperation makes reference to the
interaction of persons or groups of persons representing various
nations, in the pursuit of a common goal or interest.
7. Identify a twinning lead and deputy at each partner

institution. Ideally the Quality Improvement Officer
should be the designated lead. In the absence of a
Quality Officer, a focal point responsible for quality
and safety can be designated instead.
8. Ensure the engagement of multi-disciplinary staff
committed to being part of the “improvement
team”. For example, a dedicated person that
collects data and monitors evaluation activities.
Involving motivated staff will make the change
process happen smoothly and positively influence
staff who resist change.
9. Consider the suggested definition of partnership;
refine and agree on it across the twinning partners
as a foundation for moving forward.
10. Negotiate with managers to secure protected time
for the improvement team to work on the identified
technical action areas.
11. A kick-off meeting with the twinning teams is
recommended for the teams to get to know each
other. If an in-person meeting is not possible, the
alternative is a virtual meeting.
12. Establish a schedule of regular communication
(a minimum of once a month is recommended)
using a variety of methods (telephone, SMS, text
messaging, email, skype, etc.).
13. Establish a budget for the planned activities,
including overheads.
STEP 2: NEEDS ASSESSMENT

The needs assessment allows for the baseline needs
of the health facility to be identified and understood.
This forms the basis for the gap analysis and
Core resources for
ultimately, guides all future improvement activities of
Step 2 – Needs assessment
the partnership.10
(see annex 2)
10
For an example of a “How To” tool developed for the TPI
partnership situational analysis between NUH and TMH, see
annex 3.
PART 3: Digging deep - Putting the 6-Step cycle into practice 31
Main activities
1. Conduct a desk review on existing national, sub-
national and institutional documents on quality
of health services. Possible documents include:
national health sector policy/plan, national quality
policy or strategy.
2. Identify experienced and motivated leads to
coordinate the assessment, as well as their
assessment team members. The composition
of the team will depend on the scope of the
assessment, the time and resources available.
Ideally the team should include a member from the
district health management, the health care facility
management and an expert of the technical area
to be assessed.
3. All members of the assessment team should be
briefed before starting the assessment and have
an overview of the expected results of the exercise,
including the data collection process.
4. Communicate to other facility staff about this
exercise as it requires the collaboration of other
teams when collecting data, ensure buy-in from
the start and discuss confidentiality.
5. Undertake a specific needs assessment within
the selected technical area using appropriate
assessment tools. Examples of themes that could
be assessed are:
a. infection prevention and control
b. patient safety and health worker safety
c. essential surgical care
d. waste management
e. Water, sanitation and hygiene (WASH)
f. maternal and newborn care
Outputs or deliverables
g. health workforce. Completed baseline and situational
analysis report appropriate to technical
6. Consider the use of a standardized tool to
area of focus.
complete the needs assessment. See annex 3, as
an example of the tool developed and then used
for the TMH needs assessment.
Consider any assessments that have been undertaken

in any of these areas in the past 6-12 months and
gather together assessment results and expertise that
can be a source of valuable learning.
STEP 3. GAP ANALYSIS

The Gap analysis is a review of the needs
assessments and reveals key priority areas for
improvement action. The systematic gap analysis Core resources for
is the foundation for action planning that can help Step 3 – Gap analysis
partners to implement a more focused improvement (see annex 2)
effort. While analysis can reveal several gaps, not all
of them would be appropriate for addressing within
the context of the partnership. It is recommended to
choose two or three areas of priority intervention to
ensure that the desired improvements can be made.11
Main activities
1. Organize a face-to-face or virtual meeting with the
improvement teams of each arm of the partnership Outputs or
to discuss the results of the situational analysis
conducted in Step 2. deliverables
2. Analyse and interpret the data and information
1. A gap analysis report
collected.
containing the current
3. Using the findings of the baseline and situational situation and desired
analysis, develop a list of gaps that require improvements. This
improvement action and whenever possible, the report should outline what
causes of the gaps. constitutes the gap and the
4. From the list of gaps, identify priority areas based factors contributing to it.
on urgency and the human and financial resources 2. A list of priorities and
available. indicators based on the
5. Define the indicators to be included in the capacities of both arms of
improvement plan. the partnership to address
the gaps identified.
6. Focus on small-scale, simple actions.
11
In completing the gap analysis following Step 2, the TPI between
TMH and NUH conducted a Partnership Planning Workshop to
review the gaps and determine the priorities moving forward. For
a full report, see Step 3 of Annex 2.
7. Outline specific steps that can be taken to fill the

gaps.
8. Organize a meeting with senior leadership to
secure endorsement and approval of the findings
of the gap analysis and the priority areas
identified.
Quality Improvement (QI) at the core of TPI

The TPI Preparation Package outlines all six steps and provides support
and guidance for initiating the partnership and prioritizing which areas
in service delivery or care need improvement. In addition to this TPI
Preparation Package, a detailed practical field guide entitled “Taking Action:
Steps 4 and 5 for Twinning Partnerships for Improvement” can be read
alongside the overview of Steps 4 and 5 below. “Taking Action” dives into QI
models and approaches and supports the planning, action, implementation,
and guidance of QI within partnerships. “Taking Action” reviews the
theories of practical application of action in a partnership and can be used
by any QI team that has identified a quality challenge, specific needs and
current gaps in services; and also that is ready to develop targeted action
plans for intervention and improvement in health care setting.
The “Taking Action” document also includes a list of common barriers

and key factors for successful quality improvement gathered through the
WHO Global Learning Laboratory for Quality UHC. The seven countries
which provided feedback on common barriers and key factors for success
included India, Malawi, Mexico, Nigeria, the United Kingdom, Venezuela and
Zimbabwe. The feedback provided critical insights from the front line on the
challenges and opportunities for quality improvement at the facility level.
For additional information and for the common barriers and key factors,
please refer to “Taking Action: Steps 4 & 5 in Twinning Partnerships for
Improvement.”
For additional information on the WHO Global Learning Laboratory, visit:

http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/
STEP 4: ACTION PLANNING

Action planning brings partners to a jointly agreed
written plan of action. This action plan is grounded in
the gap analysis and sets clear short-term and long-
term targets for the twinning partnership (12). In this
Step, it is important to also consider matters related
to communication, spread and budget.12 Core resources for
Step 4 – Action Planning
Main activities (see annex 2)
1. Hold a team meeting at the partnership facility

• Identify and confirm the key team members
at the partnership facility:
• Facility leader or manager to endorse
the partnership
• QI team leader with dedicated time for
the project
• Technical/clinical/subject matter expert
• Measurement and evaluation leader
• Community/patient representative
• QI team staff to provide technical and
administrative support
• Ensure consensus and common
understanding of key definitions
• Outline preparation activities
• Review activities taken to date on Steps
1 to 3 of 6-Step Cycle
• Ensure team is prepared with priority
areas already identified
• Assess ground level interest and
capacity
• Estimate expected costs in terms of
personnel, time and money.
2. Agree on an intervention
• Review evidence for possible interventions,
focusing on improved outcomes
• Seek relevant resources on all relevant
12
For an example of action planning templates, see Annexes 4-6
literature on the subject area

• Consult with experts on site and at
partnership sites
• Consult with other health workers
• Select intervention with largest benefit,
lowest barriers to use, and greatest potential
for sustainability
• Carefully consider how technical
exchanges can support the intervention
• Note sustainability of interventions
post-partnership
• Break down interventions into necessary
behaviours, structural and procedural
changes.
3. Outline implementation activities
• Outline implementation plans
• Summarize roles and responsibilities
for implementing various aspects of the
intervention
• Identify local barriers to implementation and
design accordingly13
• Engage stakeholders to identify
potential concerns
• Identify needs based on local context
• Identify potential gains and losses
associated with implementation
• Evaluate current communication methods
and adapt as needed.
4. Outline roles and ensure capacity
• Estimate expected expenditure
• Estimate costs/time for team members
• Estimate costs/time for supplies/
equipment
• Estimate amount of inputs and capacity
available
13
For a list of common barriers, see Taking Action Steps 4&5.
• Determine roles and responsibilities of each

team member and how they will contribute to
the improvement aim
• Ensure protected time and support for staff
• Obtain the necessary approval from the
facility leader to protect time for key
staff
• Designate an administrative support
person or other assistance
• Ensure clear roles are defined for team
members in the partnership institution and
communicated clearly across the partnership.
5. Outline monitoring and evaluation activities
• Outline monitoring activities
• Examine hospital epidemiology and
existing measures taken by hospital
• Identify key indicators of success in
implementation
• Identify key methods for collecting
evaluation data
• Outline evaluation activities
• Identify key indicators of outcomes
• Identity key methods for collecting
evaluation data
Outputs or
• Strive for simplicity in evaluation and deliverables
monitoring
1. Complete written 2-year
• Consider benchmarking success from other Partnership Plan
hospitals in similar contexts.
2. Complete written 6-month
6. Complete written action plans initial short-term action plan.
• Share preliminary plans – ensure teams in
partnership health facilities are in agreement
• Schedule a series of partnership visits with
defined objectives, including twinning partner,
other partners, country/WHO lead
(if applicable)
• Agree on a schedule of partner progress
reports (see annexes 4-6).
STEP 5: ACTION
Action marks the start of implementing the agreed
improvement activities set forth by the action
plan. By this stage, partners have established and
strategized about methods of action and have secured
communication channels for ongoing partnership
action. Reviewing progress every six months will
allow corrective measures to be taken, if needed.
The improvement team should carry out regular and
planned monitoring reviews using the indicators
previously defined. During this action stage, a method
for tracking the budget is advised (12).
Main activities
1. Put Partnership Plan into action with partners
• Ensure continuous consensus in action
between partners
• Ensure continued alignment with national and
sub-national efforts to strengthen quality of
health services
• Ensure that partners working within the
same facility are continuously aware of
improvement activities
• Align existing improvement efforts
already under way at the facility level
• Mark the moment of initial action on both
arms of the partnership
• Choose a date.
2. Manage the implementation of activities

• Set up a regular schedule for the QI team to
share updates on progress of the project
• Ensure methods are used to make data
regularly visible to staff
• Ensure involvement across the institution,
including staff members not directly involved
in the specific improvement intervention
• Ensure regularly scheduled communication
across the partnership on implementation
activities.
3. Coach the team to implement the QI activities

• Provide facilitation and QI methods training
for QI team leader
• Provide mentoring, coaching and general
on-site QI support using all assets available
(local- and partnership-based)
• Build in time for QI knowledge transfer
from the team leader to team during team
meetings, with the intention of creating
cohorts of health workers who can act as
catalysts and mentors.
4. Implement the quality initiatives and test changes
• Implement intervention
• Measure performance through small test
of change – PDSA cycles or other agreed
methods
• Keep track of progress against the planned
activities and budget
• Make adjustments to intervention based
on information received, e.g. outcomes and
feedback in response to small test of change
• Document issues that arise in a log, and how
they were tackled
• Set up rapid response mechanisms for
trouble-shooting with partners.
5. Assess and refine the interventions
• Implement review every six months
• Develop interval reports
• Adjust team efforts accordingly
• Adjust any changes due to staff
turnover, need for capacity-building,
or need for re-training or training of
additional staff
• Report back to the partnership on
issues that arise14
14
For an example of a partnership that confronted failure,
see annex 1.
• Celebrate small or large victories on

both arms of the partnership.
6. Share learning and spread changes
• Continuously refine change until ready for
implementation on a broader scale
• Implement a spread plan, taking careful
consideration of sub-national and national
contexts
• Spread changes, taking a successful
implementation process from pilot
and replicating change throughout the
organization
• Identify opportunities to use partnership
activities to bring about change in
other institutions, encouraging national
spread. 1. Develop a series of reports outlining
7. Document and disseminate the improvements action and progress in partnership plan
observed 2. Conduct mid-term review of
• Distil the change stories implementation activities.
• Distil learnings on implementation by
developing knowledge products15 such as
knowledge briefs and action briefs
• Synthesize any learning to have emerged
from one arm of the partnership that
benefitted the other arm, emphasizing the
bidirectional nature of learning
• Disseminate a progress report using
appropriate bodies at national, subnational
and local levels to maintain to maintain
dialogue and connection to overall national
plans.
15
Visit the WHO Global Learning Laboratory for more information
on Knowledge Briefs.
STEP 6: EVALUATION
Evaluation and review enables twinning partnerships
to assess the impact of both their technical
improvement work (against their baseline) and the
strength and functioning of their twinning relations.
This reflects on the strengths and gaps of the
partnerships so that refinements can be made. Core resources for
Step 6 – Evaluation
Monitoring and evaluation are key components for and Review (see annex 2)
a successful partnership and must be implemented
from the outset of the partnership cycle (13). This step
marks the closure of the cycle and allows the partners
to review and assess how well the partnership has
met its objectives, but also the partnership’s true
impact. The evaluation is the final stage, but the
monitoring has taken place thorough the cycle and the
results will inform the overall assessment. In addition
to local review meetings and partnership discussions,
each twinning partnership provides periodic
monitoring reports (6-month reports; 1-year repeated
baseline assessment; and a 2-year review).
Some suggest an external evaluation by specialists

to ensure objectivity and others suggest using the
teams within the project to gather optimal learning.
A combination of the two approaches can generate
better results and partner satisfaction (13). Whatever
is decided, the partners should be involved in the
exercise; specialists should be responsible for
certain aspects of the evaluation, and the evaluation
and monitoring process must be planned for at the
beginning of the partnership.
By including the three objectives as an underpinning

structure of the evaluation, a successful evaluation
reflects on the strength of the partnership, the priority
areas of improvement, along with its spread.
Main activities
Initial evaluation planning activities should be
conducted in earlier parts of the 6-step partnership
cycle. This planning activity should include
consideration of:
• key indicators on the effectiveness of the

improvement effort
• assessment of partnership strength
• spread beyond the partnership
• training on evaluation approaches for those
involved in the partnership
• periodicity of reporting.
Evaluation activities are conducted throughout the 6

steps. Step 6 is focused on activities to synthesize
findings, as well as conducting any necessary
assessments.
1. The partners together review the monitoring
reports and decide how to synthesize evaluation
(collection of statistical data, interviews, focus
group, surveys, etc.)
2. Synthesize findings from key indicators that
demonstrate effectiveness of the activities
conducted, as well as the long-term impact of the
partnership.
3. Prepare an evaluation report based on the actions
outlined in the partnership plan (and informed by
appropriate evaluation tools).
4. Reflect on the success of the evaluation training.
5. Conduct a repeat of the baseline assessment/ 1. For a 2-year project, three monitoring
situational analysis to consider progress. reports should be generated and
6. Conduct assessment on the strength of the shared across the partnership and
collaboration. with hospital leaders outlining action
and progress towards achieving the
7. Conduct assessment of the spread activities. Partnership Plan (at 6 months, 1 year
8. Synthesize all findings and agree on key lessons and 2 years).
learned (consider limiting to top ten). 2. Repeated baseline assessment/
9. Prepare an evaluation report to demonstrate situational analysis.
impact and to advocate for financial support. The 3. Evaluation report
reports will focus on the achievement of project
outputs and outcomes.
10. Disseminate findings internally and externally.
KEEPING THE
LEARNING GOING
T
here have been notable successes among
the hospitals and health systems that
have participated in partnership-based
approaches to improvement. These include sustained
partnerships, co-developed products and programmes
and spread. It has become clear, that in many cases,
neither the technical experts from high-income
settings, nor the local providers from low-income
institutions have sufficient knowledge and know-
how to affect improvements. Strong, trusting, inter-
institutional partnerships are therefore needed to
co-develop solutions that can lead to success and
spread. Linkages with national efforts to enhance
quality are key to successful cascading of learning for
maximal impact on health outcomes.
The 6-Step Partnership Improvement Cycle and the
TPI Preparation Package provide a practical blueprint
for action. It should be noted, however, that each
partnership is different - adaptation will invariably
be required. Learning will certainly emerge, and this
document will also be improved over time.
Quality improvement is still an evolving science,

and humility is essential for partners on all sides of
the TPI. Indeed, successful partnering is rewarding
for all those involved. There is much to be learned
about how to apply the principles and practices of
quality improvement to strengthen the delivery of
health services and build resilient health systems
in developing countries, yet, lessons also flow back
to the so-called developed world. The prototype
partnership between Tellewoyan Memorial Hospital
in Liberia and Nagasaki University Hospital in Japan
proved invaluable in informing the design of the larger
TPI initiative. The experiences from this and other
efforts will help refine the different approaches to
quality improvement. These experiences can also
inform and be informed by wider efforts on quality,
which have become increasingly prominent in the
context of continued advancement of global efforts to
achieve universal health coverage.
Resources are limited, and continued global learning

about quality improvement will depend on the sharing
of knowledge, experiences and ideas. Entities such
as the WHO Global Learning Laboratory (GLL) for Quality
UHC can foster such sharing. The GLL is also a space
where successes can be celebrated and knowledge,
experience, and ideas shared. Sometimes there
is failure, but resilience is needed to find a way to
succeed – a huge body of learning resides in these
initial failures. The words of Benjamin Franklin ring
true - “Tell me and I forget, teach me and I may
remember, involve me and I learn.” That is the power
of human interaction that lies at the heart of a
partnership.
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ument/pdtoolkit_en.pdf, accessed
of innovations in health service
13 April 2018).
delivery and organisation. Re-
ANNEXES
ANNEX 1
Case study - Adjusting action when it’s not working
Developing a culture of learning in Malawi16
Partnerships work together to identify what works,
what does not and what can be learned from this.
The Zomba Mental Health Services (Malawi)
partnered with the Department of Health Sciences
at the University of York (UK) and worked together
on a project designed to strengthen the system of
community mental health care in Zomba District,
Malawi. The project aimed to develop the role of
local village-based health workers, known as health
surveillance assistants (HSAs), through training and
support, in delivering mental health interventions
16
This partnership was supported by THET.
for the first time. Planning and paper copies of the data would
delivery of the project involved be taken off-site between visits,
key professionals in Zomba and that the timescales should
from mental health services and be allowed to slip. This affected
district health offices, as well as the progress of the partnership
discussions with the HSAs. improvements and the colleagues
involved agreed to improvise and
To collect data, the project adjust the action planning.
manager of Zomba conducted
visits to the village-based HSAs The project manager of Zomba
on a monthly basis. This allowed believes that learning has been
him to capture relevant data and facilitated by the partners having
discuss it with them. This process respect for each other’s views
allowed them to engage HSAs in and ideas, and making decisions
the project as a whole. “It enthused collectively. “The UK partner
people, kept them motivated was very supportive of our new
and interested, and kept the ideas on the implementation of
momentum of the project going. the work. This has helped the
This wouldn’t have happened if we partnership to work better together
hadn’t built in face-to-face visits”, for one common goal, evidenced
admitted the project manager. in the successful results. In the
process, the Malawi partners
There were practical difficulties have gained knowledge and learnt
and the data required for skills, including in relation to good
monitoring and evaluation was not project and financial management,
efficiently collected. The project and analysis, interpretation and
manager of Zomba had planned to reporting of data.”
capture all data on his laptop on a
monthly visits, but this proved too Acknowledging problems allows
time-consuming. Having realized partners to look for solutions
the data collection system was and turn challenges into lessons
not working, the team agreed that learned.
ANNEX 2. TOOLS AND RESOURCES

The tools and resources listed below aim to provide support in the development and
execution of your action plan. The resources are diverse and span, not exclusively, advocacy,
business/financial, guidance/policies/standards, templates, toolkits and selected academic
publications. The resources are included after careful review of WHO materials. Inclusion
of a resource is based on its perceived usefulness and also its availability. Inclusion of a
resource does not imply endorsement by WHO of any specific organization associated with
the resource.
Many tools and resources that are applicable in hospitals can be accessed through the WHO
website of Hospital of the XXI Century: http://www.who.int/hospitals/en/
Core resources for Step 1 – Partnership development
Type of resource Location
Starting a health https://www.thet.org/wp-content/uploads/2017/09/How-to-start-a-Health-Partnership.pdf

partnership (THET)
Example of letter of http://www.who.int/patientsafety/implementation/apps/APPS_registration/en/

commitment
Example of memorandum of https://www.thet.org/wp-content/uploads/2017/09/Memorandum-of-Understanding-Template.

understanding pdf
La coopération https://www.fhf.fr/Europe-International/La-cooperation-internationale/
internationale hospitalière – Guide-cooperation-internationale-hospitaliere
guide des bonnes pratiques.
(French Hospital Federation)
Guide de la coopération https://www.cultura.com/guide-de-la-cooperation-hospitaliere-pour-l-aide-au-

hospitalière pour l’aide au developpement-9782859526849.html
développement
Successful partnerships, a https://www.oecd.org/cfe/leed/36279186.pdf

guide of OECD
Position Statement - http://www.who.int/patientsafety/implementation/apps/global-catalyst-group.pdf

Global Catalyst Group
for Institutional Health
Partnerships
Annexes 49
Core resources for Step 2 – Needs assessment

The needs assessment tools that you see below are not exhaustive. They were identified
from the process undertaken by the partnership prototype between Tellewoyan Memorial
Hospital and Nagasaki University Hospital.
Type of resource Location Year of

publication
Situational analysis for patient safety. A tool to http://www.who.int/servicedeliverysafety/ 2009, revised
assess the current level of patient safety in a twinning-partnerships/tools/en/ in 2015
IPC and health care facility based on 12 action areas
patient safety
WHO Hand hygiene Self-Assessment Framework. http://www.who.int/gpsc/country_work/ 2010
A critical first step in improving hand hygiene in a hhsa_framework_October_2010.pdf
health facility is to complete this assessment
Twinning Partnerships for Improvement. http://apps.who.int/iris/bitstream/10665/2 2017
Situational assessment report: quality and patient 53523/1/9789241511872-eng.pdf?ua=1
safety- Tellewoyan Memorial Hospital and Lofa
County Health System
A tool for Infection prevention and control for http://www.who.int/infection-prevention/ 2017
supporting national implementation through tools/core-components/ICPAT2.pdf
effective baseline assessment and evaluation
Workforce Human Resource Management Rapid Assessment http://www.lmgforhealth.org/sites/default/ 2005
Tool for Public and Private-Sector Health files/HRM_Rapid_Assessment_Tool_0.pdf
Organizations
Guidelines: Incentives for health professionals. http://www.who.int/workforcealliance/doc- 2008
This underlines both financial and non-financial uments/Incentives_Guidelines%20EN.pdf
incentives as critical to ensuring effective
recruitment, retention and performance of health
workers across the world.
Water, WASH FIT. A practical guide for improving quality http://www.who.int/water_sanitation_ 2017
sanitation and of care through water sanitation and hygiene in health/publications/water-and-sanita-
hygiene health care facilities tion-for-health-facility-improvement-tool/
en/
Health service Service availability and readiness assessment http://apps.who.int/iris/bit- 2015

delivery (SARA). A tool to assess and monitor service stream/10665/104075/1/WHO_HIS_HSI_
management delivery in terms of availability and readiness of RME_2013_1_eng.pdf
the health sector and to generate evidence to
support the planning and managing of a health
system
Situational analysis of quality improvement http://www.tzdpg.or.tz/fileadmin/ 2012
in health care, Tanzania. This analysis covers documents/dpg_internal/dpg_work-
the current status of QI work, standards and ing_groups_clusters/cluster_2/
their assessment, indicators for QI, methods health/Sub_Sector_Group/Quality_
and approaches in use, progress made, SWOC Assurance/11.a_Situation_Analysis_of_
analysis. Quality_Improvement_in_Health_Care_
Tanzania_-_Final.pdf
Essential sur- Tool for Situational Analysis to Assess Emergency http://www.who.int/surgery/publications/ 2012
gical care and Essential Surgical Care s15986e.pdf?ua=1
Core resources for Step 3 – Gap analysis
Year of
publication
Gap Implementing a gap analysis framework to im- https://www.usaidassist.org/sites/assist/files/ 2010
analysis prove quality of care for your patients. USAID hci.ghc_gap_framework_workbook.14jun10_1.
case study showing a gap analysis step-by-step. pdf
Gap AHRQ Quality indicators toolkit – Instructions for https://archive.ahrq.gov/professionals/systems/ 2012

analysis doing a gap analysis hospital/qitoolkit/d5-gapanalysis.pdf
Practical Twinning Partnerships for Improvement. Japan- http://www.who.int/servicedeliverysafety/twin- 2016

resource Liberia Partner Planning Workshop Report ning-partnerships/partnership-planning-report.
pdf
Core resources for Step 4 – Action Planning

The WHO Recovery Toolkit, accessible here, is a library of guidance resources in a single place
which can be quickly and easily accessed, to guide action. A key purpose of the Recovery
Toolkit is to support countries in the reactivation of health services which may have suffered
as a result of a large-scale emergency. These services include ongoing programmes such as
immunization and vaccinations, maternal and child health services, and noncommunicable
diseases. In addition, and because the Toolkit contains core information needed to achieve
functioning national health systems, it also supports countries with implementation of their
national health plans during the recovery phase following a public health emergency.
Year of
publication
Knowledge Translating evidence into practice: a model for http://www.bmj.com/content/337/bmj. 2008
translation large scale knowledge translation a1714
Planning and WHO planning and implementation of district http://www.who.int/management/ 2004
implementation health services district/planning_budgeting/
PlanningImplementationDHSAFROMd4.
pdf?ua=1
WHO implementation strategy and tools. A guide http://apps.who.int/iris/bit- 2009
to implementation of the WHO Multimodal Hand stream/10665/70030/1/WHO_IER_
Hygiene Improvement Strategy PSP_2009.02_eng.pdf?ua=1
Implementation tools and resources for http://www.who.int/infection-prevention/ 2018
supporting facility and national level tools/core-components/en/
implementation of the WHO Guidelines on Core
Components of Infection Prevention and Control
Programmes
Guidelines on core components of infection http://apps.who.int/iris/bitstream/10 2017
prevention and control programmes at the 665/251730/1/9789241549929-eng.
national and acute health care facility level. pdf?ua=1
Evidence-based guideline to support countries
as they develop and execute their national
antimicrobial resistance (AMR) action plans.
Planning and implementation of district health http://www.who.int/management/ 2004
services. 10 steps in planning, essential health district/planning_budgeting/
package, health systems research, disaster PlanningImplementationDHSAFROMd4.
preparedness pdf?ua=1
Annexes 51
Tools for assessing the operationality of district http://www.who.int/management/dis- 2003

health. A set of tools aimed at district health trict/assessment/assessment_tool.pdf
management teams to generate the information
that will serve as a basis for improving the
operationality of health districts
WHO Safe management of wastes from health http://www.searo.who.int/srilanka/doc- 2014
care activities. Provides comprehensive guidance uments/safe_management_of_wastes_
on safe, efficient and environmentally sound from_healthcare_activities.pdf?ua=1
methods for the handling and disposal of
health care waste in normal situations and also
emergencies.
Sanitation Safety Planning (Implementation http://apps.who.int/iris/bitstre 2015
tool). Manual for safe use and disposal of am/10665/171753/1/9789241549240_
wastewater, greywater and excreta. eng.pdf?ua=1
WHO - Workload indicators of Staffing Needs http://www.who.int/hrh/resources/ 2010
(WISN) – User’s Manual WISN_Eng_UsersManual.pdf?ua=1
Association for Professionals in Infection Control http://www.apic.org/Resources/
and Epidemiology (APIC) HAI cost calculator: Cost-calculators
Core resources for Step 6 – Evaluation and Review
Year of
publication
Monitoring and M&E planning tool for both implementing and https://www.thet.org/resources/ 2014
evaluation reviewing M&E plans hps-monitoring-evaluation-plan/
Evaluation FAQs Step-by-step guide for health partnerships https://www.thet.org/resources/ 2014

to effectively carry out an evaluation of their health-partnerships-evaluation-faq/
projects and partnerships in the form of
frequently asked questions.
APPS -Evaluation A guide to evaluate five domains of a partnership: http://www.who.int/patientsafe- 2012
Handbook situational analysis, partnership strength, patient ty/implementation/apps/
safety improvements, patient safety spread and Evaluation-Handbook_EN.pdf?ua=1
annual evaluation report
Monitoring, Webinar: sharing of experiences to provide some https://www.youtube.com/ 2016
evaluation and reflections around M&E watch?v=v_oHEvgE_aA
learning
Monitoring and Health partnership symposium on monitoring, https://www.thet.org/wp-content/ 2017
evaluation evaluation and learning. Document gathering tips uploads/2017/09/Monitoring-and-
to understand the value of M&E. Examples and Evaluation.pdf
exercises are provided.
Monitoring and EFFECt tool stands for EFFective in Embedding https://esther.eu/index.php/effect-tool/ 2017
evaluation Change. This tools focuses on assessing
implementation best practice, embedding
change and the added benefits to individuals and
institutions using a partnership approach
Core resources for improvement
Type of resource Location Year

PDSA Cycle Systematic process for gaining https://deming.org/explore/p-d-s-a 2018
(Plan-Do-Study-Act) valuable learning and knowledge for
the continual improvement
Model for improvement The Model for Improvement, is http://www.ihi.org/resources/Pages/ 2018
a simple, yet powerful tool for HowtoImprove/default.aspx
accelerating improvement
Confronting staffing Understanding the barriers to https://bmchealthservres.biomedcentral.com/ 2014

issues and turnover of setting up a health care quality articles/10.1186/1472-6963-14-1
health facility staff improvement process in resource-
limited settings: a situational
analysis at the Medical Department
of Kamuzu Central Hospital in
Lilongwe, Malawi
WHO Multimodal A one-page visual describing the http://www.who.int/infection-prevention/publi- 2017
Improvement Strategy five-part multimodal strategy to cations/ipc-cc-mis.pdf?ua=1
support IPC improvement in a
health care facility
Annexes 53
ANNEX 3. TPI SITUATIONAL ASSESSMENT “HOW TO” TOOL EXAMPLE

Step 2: TPI Situational Assessment “How To” Tool
The following “how to” tool is presented as a practical guide explaining steps to plan
and execute an in-depth situational assessment to inform a twining partnership
initiative between two interested partner institutions. This assessment seeks to provide
a foundational basis for the co-development of an effective and sustainable twinning
partnership between partner institutions. This “how to” tool informs the process of
conducting Step 2 of the 6-Step Partnership Improvement Cycle. The “how to” document is
to be used together with the TPI Preparation Package and its associated resources.
Pre-Assessment: Deconstruct Assessment: Learn Post-Assessment: Build
(minimum 4 weeks prior to assessment) (10 days in-country) (4 weeks post-assessment)
OBJECTIVE: REVIEW IN-COUNTRY NATIONAL DOCUMENTS, IDENTIFY QI OPPORTUNITIES AND RELEVANT IN-COUNTRY PARTNERS
• Identify experienced and motivated lead person to coordinate assessment
OBJECTIVE: BUILD RELATIONSHIPS AND LEARN FROM FRONT-LINE PERSPECTIVES

• Conduct team exercise with health facility staff and
OBJECTIVE: TRANSLATE FINDING, SHARE WITH KEY STAKEHOLDERS AND INITIATE ACTION PLANNING PROCESS
• Develop and finalize detailed assessment report in
• Inform WHO country office and regional office of impending situational district health team to gain: collaboration with the thematic lead persons, seeking
assessment • an understanding of the partner institutions any approvals where required
• Conduct desk review of existing national, sub-national and institutional • current understanding on quality and safety • Develop short story from assessment highlighting
documents on quality and safety. Possible documents include: within local context. quality improvement and safety opportunities and
• National health sector policy/plan • Consult TPI Preparation Package for core technical share with WHO Learning Laboratory for Quality
• National quality health strategy tools and resources used for Step 2 Universal Health Coverage network
• District/county-level operational or work plan • Identify key informant(s). Individual(s) should be a • Participate in action-planning workshop for the twining
• Health facility annual plan or workplan respected person amongst his/her peers. partnership initiative presenting summary of the
• artner coordination mechanisms • Review interview guide with key informants or group scoping mission findings and recommendations
• In-country quality of care measurement documents/projects and collectively refine tool to adapt to local context. • Co-develop a partnership plan around the focused
• Identify areas you intend to evaluate during the assessment. Ideally, all five • Key informant schedules interview times with health action areas identified by partner institutions
assessment thematic areas should be considered: worker (HW) cohort. Recommendation for focused • Use the assessment results to form the basis of the
• Quality Improvement group discussions (FGD) with homogenous health TPI partnership plan development
• Patient Safety (PS) worker cohort, if total cohort number exceeds five. • Provide feedback to WHO TPI team on assessment
• Hand Hygiene (HH) Small homogenous groups allow for open discussion planning checklist
• District-level health system and confidentiality • Discuss opportunities to leverage partner initiatives to
• Patient & Community Perspective • During day of HH and PS assessment, do not hold support bottlenecks identified at district-/country-level
• Review long-form of interview guide addressing any unanswered questions any FGD. This is to allow limited HW participation in • During Steps 4-6 of TPI cycle, consult quality
that arise assessment. improvement resources in TPI preparation package for
• Determine situational assessment schedule and share with WCO • Collect, analyse and crosslink data for all five thematic action steps and evaluation/ review.
• WCO country office to schedule meetings in-country and facilitate facility/ areas daily • Conduct evaluation assessment as part of Step 6 of
district site visit • Summarize and present preliminary findings to: partnership Improvement cycle
• Identify composition of mission team and assign lead roles for five thematic • Hospital staff and district level staff • Conduct Situational assessment on an annual basis
areas • WHO Country Office/Ministry of Health ( as needed)
• Ideally, team should include representation from MOH, multiple levels of the • Relevant partners such as funding agency • Align and build monitoring and evaluation system
organization (if available) and the partner institutions • Summarize preliminary recommendations according for the partnership with in-country quality of care
• Ensure availability of relevant skill set, aligned with selected thematic areas to actions needed for different stakeholders: measurement initiatives
• Identify relevant development partners/stakeholders to be consulted • TPI initiative • Consult TPI quality improvement resources for hospital
• Initiate series of coordination calls and email exchange with assessment • Health facility partnerships to inform monitoring and evaluation
team to discuss technical scope of mission and logistics • District health team system of the partnership
• If funding allows, initiate scoping mission to sensitize Ministry officials and • Ministry of Health
partners in-country ( if funding does not allow, initiate as part of in-country • Hold daily assessment team meeting to debrief from
assessment) day’s activities, address emerging key issues and
prepare for next day
FACILITY- LEVEL DISTRICT/COUNTY-LEVEL

EXAMPLES OF
HEALTH
WORKER
COHORT
• Clinical staff: doctor, physician assistant, • Hospital Management • Health Boards • District/County Superintendent, District Commissioners, Traditional
nurses, midwives, pharmacist, lab technician, • Patient & Community Representatives • Management Teams chiefs
aides etc. • Partners within Health Facility • Health Structure Directors • Partners
• Non-clinical staff: maintenance staff, cleaners
Annexes 55
ANNEX 4. TPI PLANNING TEMPLATE
SUMMARY INFORMATION
Name of twinning Name of lead:

institution 1:
Name of twinning Name of lead:
institution 2:
Name and date of Names of individuals completing the plan:
situational analysis/
baseline assessments
used:
Technical action areas for Example:
focus:
Partners to consider Project 1: Infection prevention and control
specific areas to work
on, based on situational
analysis (experience Project 2: Knowledge and competency on quality improvement.
highlights the need
to focus on 2-3 areas
maximum)
For each action area, complete the template below. Use as many forms as required depending on the additional action areas
addressed.
Project number and • E.g. Project 1: Infection prevention and control
action area
Brief description of • Provide a 1-2 sentence outline of the project
project
Project goals • List the change the project will contribute to in 1- 2 sentences.
• Where possible, link to national and/or local policies and plans including the national direction on
quality.
• Try to emphasize how the goals of the project respond to the needs identified in the baseline
assessment.
Project outcome(s) • Describe the improvement that you hope will result from the project.
• Outcomes often relate to changes in practice or health outcomes.
• The outcomes should contribute to the achievement of the goal.
Project output(s) • The direct results of the project e.g. 20 people trained in infection control. The outputs should
lead to achievement of the outcomes.
Main activities • List all planned activities. For each activity, briefly outline what will be done; where and who will
be involved on each side of the twinning partnership; how long it will take; methods to be used;
and associated costs.
• List technical exchange schedule ie. Fortnightly skype connection, monthly leads 1-to-1,
6-monthly visits, ...
• Is a visit planned in conjunction with this project? (if yes, list likely human and financial costs.)
• Twinning visit plans for year 1 should be thought through in detail. Plans for year 2 may be more
general. Include a draft timeline.
• What mechanisms are planned to allow receipt of just-in-time input to technical issues?
• How will you connect with WHO efforts to support quality improvement?
Beneficiaries • Include information about the people who will benefit (directly and indirectly) from the project
e.g. lab technicians; hospital managers; nurses and different groups of patient and community
members.
• Describe how they will benefit and provide realistic estimates of how many people in each group
will benefit.
• Will benefits span both sides of the twinning partnership?
Stakeholders • Identify the key stakeholders and their interest in the project (e.g. other department, district
and national health offices) i.e. any individual or group that may exert influence over the project
activities and outcomes (across both arms of the partnership).
• Consider the local community and key stakeholders, including patients and families who could
contribute and add value to the planned efforts.
• Outline which stakeholders the twinning partnership will report to and how often.
Monitoring and • Define key indicators to be used to monitor whether the outcomes of your project have been
evaluation achieved.
• Provide an overview of your monitoring and evaluation plans, providing an outline of methods,
who will be involved, how the process will be managed, and how partners will learn together.
Sustainability and spread • Describe how long the activities will continue and what the plans are for long-term funding.
• What benefits will continue after the initial 2-year project ends and how?
• List your plans for building on project achievements.
• Describe how you will actively disseminate new information gathered and consider activities to
support vertical, horizontal and spontaneous spread opportunities.
Risks • Identify potential risks associated with the plan e.g. key personnel moving on, changing
institutional priorities, conflict between twinning partners, and how you will manage each of
these risks.
• List external risks and how you will manage them (e.g. ICT breakdown, problems with visas,
political uncertainty).
Project management and • Outline project responsibilities including division of responsibilities across the twinning
support partnership.
• Provide details of the key personnel involved in each arm of the partnership.
• Consider key management questions: What systems will be used to manage finances in
both locations? Who will have the main responsibility for budgets? How will you ensure that
communication is effective and that all partners know what is happening?
Approved by
Date of approval
Annexes 57
ANNEX 5. TPI VISIT PROPOSAL TEMPLATE

The Visit proposal template should be completed once a visit has been agreed, to ensure
that the visit has clear objectives and contributes to the overall partnership planning.
Twinning partnership (list both institutions within the partnership): Institution 1:
Institution 2:
Name of person completing the visit proposal form:
Purpose of visit - describe which partnership project(s) the visit relates to:
What are the dates of the proposed visit? Start date:
End date:
Is the visit aligned with existing in-country activity with no duplication of Yes  No  Not applicable 
training or policy development work?
Does the visit clearly meet the needs of the twinning partner institutions? Yes  No  Not applicable 
Briefly describe the expected outcomes of the planned visit (outcomes are
clear, realistic and logical):
Briefly describe the outputs of the planned visit (outputs are clear, realistic
and logical):
Briefly describe any risks you think might be associated with the visit:
List estimated costs of the visit:
Briefly describe how the proposed visit will contribute to monitoring and
evaluation of the associated partnership plan:
List the number of people involved in the proposed visit and their role in
achieving the visit objectives:
Has the visit been jointly planned and agreed across the partnership? Yes  No 
Will the visit offer potential benefits to both twinning partners (if yes, de- Yes  No  Not applicable 
scribe briefly)?
Briefly describe how the visit will help achieve sustainability and spread of
effective essential health service delivery.
ANNEX 6. TPI ACTION REPORT TEMPLATE

The Action report template allows key outputs of each period of the partnership to be
documented, lessons learned and actions arising logged. This is part of developing a strong,
effective, action-focused partnership and contributes to partnership governance.
Twinning partnership (list both institutions within the partnership):

Name of person completing the report and date completed:
Time period covered by this progress report:
Key actions undertaken:
Key achievements resulting from action taken:
Key challenges faced:
Date of next expected progress report:

Annexes 59
ANNEX 7: DEFINITIONS
Accountability: The obligation to report, or give
account of one’s actions – for example, to a governing
authority through scrutiny, contract, management,
regulation and/or to an electorate.
African Partnerships for Patient Safety (APPS)

programme: The WHO APPS programme is a hospital-
to-hospital focused approach that was results-
oriented and co-developed by hospital partnerships.
Infection prevention and control, safe surgery, waste
management and health worker safety were central
elements of the African Partnerships’ work providing a
common relevant goal that everyone was committed
to improving. As a result, substantial implementation
experience and learning have been achieved in this
field across the African Region. The APPS approach
demonstrated how working in partnership results
in more motivated staff, increased commitment to
change, strengthened capacity-building, focused
drive and a desire to find appropriate solutions that
will impact immediately on the quality and safety of
patient care. This in turn can be used to strengthen
the delivery of health services to communities
globally.
Clinical effectiveness: The application of the best

knowledge, derived from research, clinical experience
and patient preferences to achieve optimal processes
and outcomes of care for patients.
Community partner: Member of a quality improvement

team representing a unit of population, often generally
geographically defined, that is the locus of basic
political and social responsibility and in which
everyday social interactions involving all or most of
the spectrum of life activities of the people within it
takes place.
Continuous Improvement: The process of making

something better or of getting better.
Integrated People-Centred Health Services (IPCHS)

framework: The IPCHS Framework calls for a
fundamental shift in the way health services are
funded, managed and delivered to respond to these
challenges. The IPCHS vision is that “All people

have equal access to quality health services that
are co-produced in a way that meets their life course
needs, are coordinated across the continuum of
care and are comprehensive, safe, effective, timely,
efficient and acceptable; and all carers are motivated,
skilled and operate in a supportive environment.”
WHO recommends five interwoven strategies that
need to be implemented in order to achieve IPCHS.
Application of the approach can build robust and
resilient health services and are critical for progress
towards universal health coverage and fulfilling the
Sustainable Development Goals.
Partnership: A partnership is a collaborative

relationship between two or more parties based on
trust, equality and mutual understanding for the
achievement of a specified goal. Partnerships involve
risks as well as benefits, making shared accountability
critical.
Patient-centredness: Providing care that is respectful

of, and responsive to, individual patient preferences,
needs and values, and ensuring that patient values
guide all clinical decisions.
Patient safety: The reduction of risk and unnecessary

harm associated with health care to an acceptable
minimum.
Performance: How well a person, team, project,

programme, organization, or policy is being
implemented against expected results.
Quality: Quality has been defined and understood

in different ways around the world. Two of the main
definitions are below.
• The degree to which health services for individuals

and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge.
• The totality of characteristics of an entity that bear
on its ability to satisfy stated and implied needs.
Annexes 61
Quality audit: a systematic and independent

examination to determine whether quality activities
and related results comply with planned arrangements
and whether these arrangements are implemented
effectively and are suitable to achieve objectives.
Quality assurance: all the planned and systematic

activities implemented within the quality system,
and demonstrated as needed, to provide adequate
confidence that an entity will fulfill requirements for
quality.
Quality control: A process to evaluate actual

performance, compare actual performance with
quality goals, and take action on the difference.
Quality improvement: A process to create beneficial

change and attain unprecedented performance.
Quality planning: A process to establish quality goals

to develop goods and services that meet customer
needs.
Stakeholder: An individual, group or organization that

has an interest in the organization and delivery of
health care.
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Partnership

© World Health Organization 2018

Suggested citation. Partnership Preparation Package - a practical guide to implementing twinning

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12 PART 1: TPI OBJECTIVES

26 PART 2: OVERVIEW OF THE 6-STEP CYCLE

PART 3: DIGGING DEEP - PUTTING THE

42 KEEPING THE LEARNING GOING

External Peer Review Group

AMR antimicrobial resistance

APIC Association for Professionals in Infection Control

APPS African Partnerships for Patient Safety

EEA ESTHER Alliance for Global Health Partnerships

GLL Global Learning Laboratory

HSAs Health Surveillance Assistants

IHF International Hospital Federation

IPC infection prevention and control

LMICs low- and middle-income countries

M&E monitoring and evaluation

NHS National Health System

NUH Nagasaki University Hospital

OECD Organisation for Economic Co-operation and Development

SARA Service Availability and Readiness Assessment

SDGs Sustainable Development Goals

SMS short message services

SWOC Strengths, weaknesses, opportunities and challenges

THET Tropical Health Education Trust

TMH Tellewayon Memorial Hospital

TPI Twinning Partnerships for Improvement

UHC universal health coverage

USAID United States Agency for International Development

WASH water, sanitation and hygiene

WISN workload indicators of staffing needs

WHO World Health Organization

of service delivery. These partnerships can act as a

PURPOSE OF THE TPI PREPARATION

Institutional health partnerships have the potential

partnerships, at local, sub-national and national level,

The TPI approach provides a measurable

The power of partnerships

Partnerships and the global goals

While TPI focuses on local, front-line improvements

Partnership development and continued

upon. Based on these identified gaps, one or several

The TPI approach provides a measurable

such as infection prevention and control (IPC), patient

Examples abound but the unifying concept is that Improvement –

from a new practice encourages both spread and

(4) Who is the target audience of the Spread? In

The work of the partnership, particularly in relation to

Spread can be considered in three ways - horizontal,

1. As soon as partners begin planning for health

5. Finally, consider, at the outset, how the experience

Horizontal spread refers to spreading improvement

Vertical spread refers to spreading the information

Spread requires strong connections between quality

Spontaneous spread, is not planned for, but can

Of further note is the necessity to consider the spread

1. Partnership development begins the

A variety of tools and resources are available

Implementing organizational and structural change

STEP 1: PARTNERSHIP DEVELOPMENT